WhiteCoat

Archive for the ‘Patient Encounters’ Category

Unique Chief Complaints

Monday, September 2nd, 2013

I’ve had a few interesting chief complaints lately. Here is a small sampling … from different patients, of course.

  • Someone broke into the patient’s house while he was sleeping and stole only his schizophrenia medications so that he would act up and then get arrested by police and have to be admitted to the hospital. Then the perpetrator could break back into his house and take all of his belongings.
  • There are two small dots near my appendicitis scar. I think something may be inside trying to crawl its way out.
  • I started having back pain after laughing too hard.
  • My left ear had been clogged after having sex 9 days ago.
  • I ran into a glass door at Home Depot. I’m not having any pain, but make sure you send them the bill for this visit.
  • A bug crawled up into my belly button and now I can’t find the bug.
  • My scars turn blue when I get cold. What is that?
  • I had left testicle pain one month ago.
  • Nurses sent a patient by ambulance after nursing home patient found doing jumping jacks in his room. He doesn’t usually act that way.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Head trauma workup

Monday, August 26th, 2013

Sculpture Human HeadPatient’s chief complaint: “I was slapped on the back of my head with a file folder by a co-worker. I have a headache and I want a CT scan to make sure there’s nothing wrong on the inside.

In other words, “I really want to get my co-worker in trouble.”

Fortunately, it wasn’t one of those goth file folders with the spikes sticking out.

Danged if I didn’t have to consider a CT of the chest after putting my stethoscope on her chest to listen to her heart … and an MRI of her back after she laid on the table for the exam.

Sheesh.

And she’ll probably end up getting the Press Ganey survey that blasts me for performing an inadequate workup on her.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Semantics

Tuesday, August 13th, 2013

A 17 year old patient comes in by ambulance for chest pain and tachycardia. His heart rate was in the 130s. He was hypertensive. He was sweating. He had a history of ADHD and was on Adderall. No other medications. No alcohol or drugs.

His exam was unimpressive and all the testing came back negative, but the patient still remained tachycardic. So we gave him a couple doses of Ativan, thinking he may have taken a little too much Adderall. Still no better. Then we started doing some additional tests to rule out the less common reasons for his symptoms. D-dimer normal. He denied alcohol or drugs, but we checked for them anyway. Tox screen normal. TSH normal.

His heart rate remained in the 140s and he was still hypertensive on re-evaluation. So the on-call doctor gets called for admission. He wants a cardiology consult. No problem.

The cardiologist recommended labetolol. Sounded like a little overkill, but we went with his recommendations.

So the patient gets started on a labetalol drip and we place the admit orders.

We go back to the room and inform the family of the discussions we had with the other doctors. The dad is not pleased.

Could this be due to him smoking that fake marijuana crap?”

“He told me he doesn’t use drugs.”

“Yeah, well he’s a f***ing little liar. He smokes it all the time. Probably smoked a bowl right before we got here.”

The patient shrugged his shoulders.

“K2 really isn’t really a ‘drug’ because they sell it over the counter … right?”

“Ummm … no. Not really.”

It’s sad that your parents are going to be stuck with a large bill for all the tests we did so that you could argue semantics.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Pain Predicament

Wednesday, July 31st, 2013

A family doctor calls to give us a heads up about a patient coming to the emergency department. He was obviously upset and sounded frustrated. He started in with the story …

I used some lidocaine a pair of tweezers, and some small scissors to remove a small lesion from a patient’s tongue. There was a little bleeding afterwards, but that seemed to stop with pressure. Then the patient said that it felt like her tongue was swelling. I thought it was from the lidocaine, so I kept her in the office and watched her for a half hour, then sent her home. They wanted some pain medication. She was allergic to codeine, so I prescribed her a few Norco pills.

The husband just called me and was screaming at me for the past 20 minutes, calling me an “asshole” and a “quack.” He said that his wife was in pain, so they went to the pharmacy to have the prescription filled. The pharmacist told them that there is a 50% likelihood of having a reaction to hydrocodone when someone has a codeine allergy. After that statement, the husband just accused me of trying to kill his wife. He wanted to know what I was going to do. I can’t give her NSAIDS because I don’t want her tongue to bleed. I’m afraid to give her any other opiates due to her allergy. Tylenol isn’t going to cut it. They called and said they’re on the way to your emergency department. What are you going to do?

His voice kept getting more and more stressed, so I tried to lighten things up a little.
“Eh, I’ll probably just give her some IV codeine and send her home.”

Dead silence.

“Did you not just hear what I explained to you?”
“Of course I heard. I was kidding.”
“Great. Now I’ve got a comedian when there’s a real problem here. Now I’M going to have to come in and manage this mess.”

And I just kept thinking to myself that Francis needs to lighten up a little.

After all that, the patient never showed up, either.

Maybe the doc referred her to another hospital whose doctors have better senses of humor.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Thanks For Watching

Saturday, July 20th, 2013

Its been a rough few weeks. The stories keep piling up on my desk. This one keeps coming to mind, so I figured I’d try to post it from my phone.*

An elderly patient came in by ambulance after tripping over a curb. She fell and hit her face, causing a nasal fracture and a periorbital contusion. But she was also having an increasing headache and she had proptosis. That’s a bad sign.

We got the CT scan of her brain and it confirmed our fears. She had a retrobulbar hematoma, meaning that there was an expanding blood clot behind her eye which was pushing her eyeball outwards against the eyelid. Because the lids push back to hold the eye in the socket, the expanding blood clot was putting increasing pressure on her eye. Too much pressure and the eyesight is gone permanently.

When we checked her vision, she was only able to see shapes out of that eye. We checked her pressure using a tonometer. It was 55. More bad news. Normal should be less than 20. We had to perform a canthotomy, meaning that we had to cut the ligament of the lower eyelid to bring down the pressure in the eyeball. A good article on performing a lateral canthotomy is here, including a drawing of what a retro-orbital hematoma looks like and why it needs to be treated.

We called two ophthalmologists to come in and help us, but neither one had ever seen a canthotomy or had done a canthotomy. Both said to send the patient to the trauma center.
Great. I did a canthotomy during a trauma rotation in my residency, so I guess we’re doing it here.

I actually let the resident perform the procedure. I helped her anesthetize the eye and I helped her guide the scissors in the right direction. Performing a canthotomy is a little more difficult than it looks [OK, I just proofread this post and there was no pun intended here]. The lateral canthal tendon is tough to cut.

As the resident was injecting the eye with lidocaine, I saw the patient her squeezing her hands in pain underneath the sterile drape.

I reached out and held one of them. Habit, I guess. Any time Mrs. WhiteCoat has a free hand, I like to be holding it.

The patient squeezed.
“Who is that?”
“It’s just one of the other doctors. You looked lonely.”
As the resident finished the procedure, I rubbed her hand back and forth and she squeezed a few times. Before we knew it, the procedure was done.
The patient thanked me for providing her moral support.
We pulled off the sterile drapes.
“So that’s what you look like.”
I smiled.
We rechecked the pressures in her eye. They had gone from 55 down to 30. Excellent.

So the resident arranged for transfer to the trauma center.
The patient’s family arrived just as the patient was being loaded onto the ambulance stretcher. I was in another room and the resident came to get me. The patient wouldn’t leave the hospital before she spoke to me.

There were several people standing around the stretcher. One by one, they came up, shook my hand, and thanked me. A couple gave me a hug, including the patient’s 4 year old great grandson who hugged my leg, although I’m sure he didn’t know why.

I told them “I think you need to be thanking the resident. She’s the one who saved your mother’s eyesight.”

Several of them chimed in together “Yeah, but you’re the one who held her hand. You were there for her when we couldn’t be.”

We called the trauma center later that day to see how the patient was doing. Pressures in her eye were down to 10. Vision was normal. A save!

It’s nice to know that she will be able so watch her great grandson’s blow out his birthday candles … with both eyes … the following week.

Sometimes emergency medicine can be pretty cool.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

*Making a WordPress post from a smart phone is a colossal exercise in frustration, by the way …

The Orthopedist’s Favorite Footwear

Thursday, June 20th, 2013

Flip Flops“Come ON! You’ve gotta be KIDDING me!” the orthopedist yelled into the phone when I called him for the third fracture of the morning. Meh. Wasn’t the phone calls. He’s always in a bad mood.

First, it was a patella fracture.
Then, it was a hip fracture.
Now, it was an open ankle fracture.

What was the common theme running through all of the fractures? The orthopedist’s favorite footwear: Flip flops.

The first patient’s flip flop caught on a curb and caused her to hit the concrete full force with her knee.
The second patient’s flip flop broke while she was trying to run to catch the bus. She got an ambulance ride instead.
The third patient gave herself a “flat tire” when she was running and had a nasty open tib/fib fracture with significant skin loss to her foot.

So, while the orthopedist was miserable because, well … he’s an orthopedist … the misfortune of others who take their chances wearing flip flops was sure keeping his practice busy. OK, OK, I’m kidding about orthopedists being miserable. Some of my most miserable best friends are orthopedists. Don’t go posting this to some orthopedics message board and start a flame war.

Remember, gentle readers, that if you absolutely must wear this flimsy footwear of horror, they don’t support your feet, they aren’t well-attached to your feet, and they aren’t running shoes. Walk slowly, don’t run in them, and don’t wear them out to the bars.

By the way, the maxillofacial surgeon on call for the day wasn’t quite as upset. I only had to call him once for a patient who had a blowout fracture of the orbit because of a face plant onto the asphalt while wearing flip-flops. I think that may have been more related to the large amount of alcohol he consumed immediately prior to said face plant, though.

Be sure to tune in next time as I discuss the orthopedist’s favorite piece of play equipment: The Trampoline.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

The Last Doctor is Always the Smartest

Monday, June 17th, 2013

Twice recently, I’ve been privy to patient complaints about emergency department “misdiagnoses” when patients have gone to follow up appointments with their physicians.

ExanthemOne case involved a young girl who had a rash. The rash was preceded by a low grade fever in the days prior, began on the chest and spread outward, and had the classic appearance of a viral exanthem. The girl’s parents weren’t happy with that diagnosis. They believed that the girl was suffering from an allergic reaction and that she needed antihistamines and steroids. The doctor explained that the rash was not an allergic-type rash and that she didn’t appear to be ingesting anything that could have caused an allergic reaction. The family left unhappy. The following day, the nurse manager gets a phone call from the patient’s irate mother. During a follow up appointment the following day, the patient’s pediatrician stated that the rash was “absolutely” an allergic reaction and immediately started the patient on Benadryl and prednisone. Oh, and the patient also had an ear infection that the emergency physician missed, so she was started on amoxicillin as well. The money quote for that call was “What type of doctors do you have working in your hospital, anyway?”
Of course, the natural course of an exanthem is that it will go away after a couple of days. So right after the patient starts taking the medications for her “allergic reaction,” her rash will get better which will reinforce the “post hoc ergo propter hoc” logical fallacy. Of course, the patient could have been given magic beans and eye of newt and she would have had the same outcome (perhaps with a little bit of an added sour stomach from the eye of newt), but it doesn’t matter because according to the pediatrician, the emergency physician misdiagnosed the cause of the rash. Of course if the patient happened to have a reaction to the amoxicillin, then the logical conclusion would be that the delay in treatment by the emergency physician caused the allergic reaction to get worse. So regardless of the outcome, the emergency physician comes out looking like a bad doctor.

CT BrainAnother case involved a patient with a severe headache. He was seen by his primary care physician and diagnosed with sinusitis. The following day, the headache had not improved on Augmentin and nasal steroids, so the patient came to the emergency department. Because it was a new-onset severe headache in a patient who never had headaches before, the emergency physician ordered a CT scan of the head. After some Imitrex and some Compazine, the headache resolved. The CT scan showed no abnormalities – including absolutely clear sinuses. Based on this, the emergency physician told the patient that he probably was suffering from migraines that he could stop taking the Augmentin and nasal steroids because the sinuses were normal on the CT scan.
Two days later, the patient returned to the emergency department in person so that he could loudly tell the registration clerks that they better watch that “dangerous doctor” working back there. A nurse intervened and the patient told her that his primary care doctor told him the emergency physician was absolutely wrong and that sinus infections absolutely can occur even without any abnormalities on CT scan, and that he needed to finish the antibiotics and keep taking the steroids — which he had thrown away after his emergency department visit. His next stop was allegedly to a lawyer’s office to look into suing the hospital.
It doesn’t matter that the medical literature shows that antibiotics and nasal steroids are ineffective as treatment for acute sinusitis. It doesn’t matter that the acute sinusitis resolved with migraine medications. It doesn’t matter that the sinuses were normal on CT scan. It only mattered that the patient’s physician was able to explain away the care rendered in the emergency department as being incompetent in a forum where the emergency physician was not present to defend himself from the criticisms.

These cases aren’t intended to illustrate that emergency physicians are always right.

Rather, they are intended to show how, even when the opinions are wrong, there is a tendency to believe that the last opinion is the correct one.

Not true.

They are also intended to show how behavior by subsequent treating physicians can anger patients and potentially lead to lawsuits.

In fact, one of these scenarios upset the emergency physician so much that there was an ethics complaint made to the hospital administration. I’d like to be a fly on the wall at that meeting.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Proving a Negative

Thursday, April 11th, 2013

Skull Medical book [morguefile.com]A young lady comes to the emergency department and wants to be evaluated for a … somewhat nonurgent … problem.

Chief complaint: “I’ve lost 50 lbs in the past month.” She felt a little weak as well, but she had just lost too much weight. No other symptoms.

The patient weighed 132 pounds. Her skin wasn’t sagging. Her jeans didn’t appear to be new and they seemed to fit pretty well. Nothing about her seemed abnormal on exam. But she insisted that she weighed 180 pounds just a month earlier.
No old records in the computer.
I asked her if she could show me a recent picture of herself on her iPhone. She briefly stopped texting to check, but she couldn’t find any.
I asked her to show me her drivers license. Nope. Didn’t have that, either.
I was quickly developing an opinion that this was a snipe hunt.

Snipe hunts like this are an example of another conundrum that many physicians face.

We are often expected to prove a negative.

Clinically, I can say that the patient did not appear to have lost 50 lbs in the past month. I can even say that it is unlikely [although not impossible – don’t comment with all your weight loss feats] that any patient could lose 50 pounds in a month.

But what if …?

What if the patient had cancer that caused some type of weight loss and I didn’t evaluate her for it? What if the patient had a bad outcome from a metabolic problem that I didn’t screen for?
What if, as a result of weight loss, the patient had developed an severe electrolyte abnormality or other blood abnormalities?

Retrospectively, if the patient suffered a bad outcome, it would be easy to allege that weight loss is an obvious symptom of [insert bad outcome here] and that Dr. WhiteCoat was careless because he didn’t evaluate the patient for this problem.

I suppose that the same issue holds true for a febrile child. If a three year old with a runny nose had a fever of 102 at home, but looks fine and is afebrile in the emergency department, he’ll probably get a pass on the workup. But if an afebrile 27 day old infant reportedly had a fever of 102 at home, get the lumbar puncture tray ready.

A physician must have a certain degree of risk tolerance in choosing whether or not to do testing to evaluate an odd complaint, but where should we draw the line between “necessary” and “unnecessary” workups?

And in case you were wondering, yes, I did labs and a chest x-ray on the incredible shrinking woman. She was anemic. Her hemoglobin was 10.5. Not enough to hospitalize her, but enough to recommend that she follow up with the on-call physician for a more thorough weight loss/anemia evaluation.

I’m going to be eating my words if she comes back next month weighing 80 pounds.

Time for a New Roommate

Wednesday, April 10th, 2013

4-10-2013 6-17-37 PMSecond time in a week.

The first episode, the patient from the assisted living facility came in with sharp anterior chest pain. She said that she was sleeping and woke up with sudden onset of pain. When she opened her eyes, her roommate was standing over her with a crazed look in her eye. Sticking out of her right breast was a ball point pen. Fortunately, the injury was to adipose tissue only and didn’t require any surgical intervention.

On her most recent visit, the same patient returned after waking to her roommate’s friend beating her with a cane. She tried to fend off her attacker and fell to the floor where the friend repeatedly pounded her in the stomach with said cane. She had a lip laceration and multiple bruises to her abdomen.

I feel so bad for this patient because she’s doing nothing wrong and getting beaten in her sleep. It’s not like a loan shark is trying to collect on a debt or anything like that.

Definitely time to find a new roommate.

Or a new facility.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Unnecessary Testing?

Thursday, April 4th, 2013

A patient was sent to the emergency department to have an ultrasound of her uterus performed.

She had been having abnormal bleeding which coincided with about the time her period was due – only it was a little heavier and lasted a little longer than usual. She decided the best course of action would be to make an emergency appointment with the gynecologist. She was seen the day before she was sent to the ED and the gynecologist performed an ultrasound in his office … which was normal.

The patient called the gynecologist the following day and said that the bleeding was still there, so the gynecologist told her to go to the emergency department for another ultrasound and some blood testing.

The patient arrived stating “I’m here for my ultrasound. Dr. Speculum sent me.” Since patients need orders for testing to be performed, the patient was given the choice of waiting to be seen in the ED or of getting a prescription from her doctor for the exam. She chose the former.

After examining her, we performed a pregnancy test which was negative and a CBC which was normal. So I told the patient she was likely just having a heavy period and that she could follow up with her gynecologist as an outpatient.
The patient demanded an ultrasound. After all, Dr. Speculum sent her to the ED specifically to have an ultrasound done.

So I called Dr. Speculum.

“Hey, it’s WhiteCoat here. Your patient is here with metrorrhagia and I’m trying to discharge her, but she insists that you want her pelvic ultrasound repeated.”
“Yeah. Can you do it?”
“Well what are we doing it to look for?”
“Fibroids”
“OK, well if she does have fibroids, are you going to admit her? Her hemoglobin is fine.”
“Noooooo. Discharge her after the ultrasound.”
“So then why … nevermind. If all you’re looking for is fibroids, weren’t you able to see that she didn’t have any fibroids on the ultrasound you did on her in the office yesterday?”
He must have really wanted that ultrasound by his response.
“Naaaaaaah. The ultrasounds I do in my office aren’t accurate.”
Allrightey, then.

The repeat ultrasound was still normal. I guess he was more accurate than he gave himself credit for.

Wonder if she’ll be referred back to the ED tomorrow for repeat pregnancy testing.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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